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, <br /> ' . ' PC Exhibit A <br /> � <br /> �t�� O'� ��'��'1� <br /> �ar�ar��e Ap�lic��i�� � <br /> Street Address: � Application# ( � Z� <br /> � ��� 2750 Keliey Parkway. Date Received: <br /> Orono, MN 55356 ' <br /> ��� � Staff: ,��.� <br /> �,a• Main: 952-249-4600 Fee: $ 00 <br /> +� ""``'� �* fiax: 952-249-4616 Renewal: $350 ' <br /> �'.�,� y� G4�' Mailing Address: After-the-fact: $1,400 Double Fee <br /> Z.q�.E�og,� P.O. Box 66 Escrow Fee: $600/$2,500 <br /> Crystal Bay, MN 55323-0066 <br /> This appfication form must be completed in full. Appficant will be notified within 15 days as to the status of the <br /> application. incomplete appiications will not be placed on Planning Commission Agendas. <br /> PROPERTY INFORMATION: <br /> Site Address: �'ZOS I�o�ZT+I S{�b� �R-• � bZonlD � +M�I SS3G4 <br /> Property Identification Number(PIN): <br /> Date Praperty Acquired (month/year): 2 201D ❑ Yes, I own the ad}acent parcels. <br /> Zoning District: <br /> APPLICANT INFORM,4TION: (Compfete legal names and marita(status required for each interested party) <br /> Name: 'r(� oTµY P�1�� KdE H�t.�(L DP��EwE rt�� I��H��fL. <br /> Phone (home): 330 • y 2► • 324 q Phone(work): Q'SZ • �LR • 04�t� <br /> Compfete Address: �� N�/t..��l SN�oR-c "D�- � o2.c�No N�tn► �3'3�4- <br /> City, Stat &Z!P 02.v nlo ,, ►'NN SS3��{ <br /> Emaif: ��A oth �-[a� u o� . �.,n Fax: <br /> OWNER tNFORMAT10At: (Complete legal names and marital status required for each interested party) <br /> Name: 'rj Wt o Ti�fK( fi►nf G- Kn ertt�- DHr!1 El1E T�ii-ot- kv�� <br /> Phone (home): 330 •�ZI • �ZUq Phone (work): �-.a,�-r'j • oy o� <br /> Complete Address: Lf'tc�� ►�(�� Sf�alL� D� <br /> City, State&ZIP R-orJ o N <br /> Email: rtit a� � a - co Fax: <br /> DESCRIPTION OF REQUEST: <br /> Describe the request in detail (attach additional sheets if necessary): <br /> - 12- RECEIV(ED� <br /> � SEP 2,1 2011 �,1; <br /> CITY OF O � � <br /> � � <br />